Is Medicare coverage available for gentle cures?

1. Introduction

The manner in which the Social Security Act defines what Medicare will consider for payment is relatively consistent with this definition. However, the AMA goes on to say that “the volume and level of physician services should be consistent with the legitimate purposes of establishing a proper physician-patient relationship and meeting the patient’s medical needs.” The ambiguity with Medicare lies in the interpretation of these laws and their application to various services. A prime example is with patients who are being seen for maintenance/wellness prevention of a particular ailment and/or prevention of an injury to an area of the body. In the PT/OT profession, patients are often seen for services related to a specific injury or a disease process such as guidance in a cardiovascular fitness program for a patient with cardiac disease, or stroke rehabilitation, which are all very obvious as to what is Medicare covered, linked to treating the illness/injury and with an expectation of significant improvement in the patient’s condition.

The American Medical Association (AMA) defines medical necessity as “healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease, or its symptoms in a manner that is: a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and duration; and considered effective for the patient’s illness, injury, or disease; and c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

Medicare provides extensive information to physicians concerning services that can be covered under the Medicare statute. There is a general consensus among both alternative therapy providers and physicians that the language in the current manual is somewhat ambiguous with regard to what is considered to be a “reasonable and necessary” service. This has ultimately been left up to individual carrier discretion and the subsequent denial or payment of claims, often resulting in increased patient liability for these services.

2. Understanding Medicare Coverage for Gentle Cures

If one were to go by the literal meaning of Medicare, it is a wide-ranging term that connotes the betterment of health for you and your family. It is a health insurance program that is administered by the US government with a view to securing health for people aged 65 or older, and people who are under 65 with certain disabilities, or those who suffer from End-Stage Renal Disease (ESRD), which is a permanent kidney failure requiring dialysis or a transplant. Medicare covers various inpatient hospital services, nursing facility care, physician services, and home health services. This insurance is not only considered a source of financial relief for the elderly but also a secure medium of ensuring physical and mental well-being. But the question is, in a society where people are hopping onto the alternative pathways for health, is Medicare really applicable for all treatments? The answer is no. Especially in today’s world, the preference for natural therapies and gentle cures has increased tremendously, and so has the availability and cost of these treatments. Unfortunately, original Medicare does not cover many alternative or complementary treatments. [1][2][3][4][5][6]

2.1 Eligibility Criteria for Medicare Coverage

Medicare conducts ongoing eligibility assessments. Patients are entitled to request a statement of eligibility at the transition of care or discharge from any given service. It is wise to request this for proof of patient status for those patients considering ongoing treatment. Services that are considered maintenance therapy are not covered by Medicare. An illness or injury is considered to be at a plateau once no significant improvement of symptoms can be expected or the condition is resolved, and the patient is no longer seeking treatment for the injury or illness in question. Maintenance therapy is defined as treatment that is designed to prevent regression of a medical condition.

Medicare offers to pay only for services that they consider reasonable and necessary for the treatment of an illness or injury (and within the state scope of practice laws). In making determinations regarding whether a service is considered reasonable and necessary, Medicare considers evidence-based national and local policies and determinations. However, it is important to remember that limitations and exclusions imposed on Medicare coverage are not easily accessible or well-defined.

2.2 Types of Gentle Cures Covered by Medicare

The panel agreed that there is a significant body of research on acupuncture, much of it testifying to its value, and clinical acupuncture research would best be served if a unified language was used to describe patient findings and related treatment. They felt that the need for a unified language using current terminology was strong and the standardization should be responsive to the language of international standardization. This is a relatively high standard for a method of treatment, which is why not all forms of acupuncture will be Medicare rebatable.

Examples of the kinds of gentle cures that Medicare will cover as part of the TCMP include techniques such as elements of Chinese (or Oriental) medicine; acupuncture; German Auricular medicine; naturopathy; Mora therapy. This requirement is in response to the 2001 Consensus Development Panel on acupuncture sponsored by the National Institutes of Health’s (NIH) Office of Alternative Medicine (now the National Center for Complementary and Alternative Medicine – NCCAM). This panel recommended that the NIH conduct or support research to evaluate acupuncture and other forms of alternative and complementary medicine.

2.3 Limitations and Restrictions on Medicare Coverage

Similarly, Medicare Part B covers only patient care services provided incident to a physician’s professional service, which according to current interpretation does not include the administration of high-risk medications such as tPA, phase II-IV chelation therapy for lead poisoning, and ECT for recurrent major depression by non-physician practitioners.

A noted limitation of Medicare Part A SNF coverage is that it does not cover the treatment or management of a patient’s medical condition, including maintenance gout therapy, IVC filters for recurrent DVT, and total parenteral nutrition for severe malnutrition.

Local and National Coverage Determinations restrict coverage of many services and treatments to particular conditions, limiting patient and provider choices, including coverage of off-label uses of drugs and devices.

The most important general restriction on Medicare coverage is that the service or treatment in question must be considered reasonable and necessary for the diagnosis or treatment of an illness or injury, often referred to as the 2-midnight rule.

There are several limitations and restrictions on Medicare coverage that impact whether or not a particular service is covered. These restrictions often represent substantial hurdles for patients attempting to access various medical treatments.

3. Exploring Alternative Options for Gentle Cures

The recently enacted State Children’s Health Insurance Program (S-CHIP) is not a viable alternative for the current population of acupuncture patients but may affect future coverage. This is similar to Medicaid, although individual states are able to expand benefits and coverage. S-CHIP offers matching funds to states to provide health insurance to families with children. Roughly 17 million children are uninsured in the United States. It is estimated that about 1% of these children with chronic pain-related conditions receive acupuncture treatment.

Patients in these plans, when compared to those with Medicare, would have to pay 35-85% of the cost for the same treatment. Patients without insurance coverage for acupuncture would have to pay 100% of the cost. Thus, under all current bicameral legislation, there would be no reimbursement for acupuncture treatment to Medicare patients or those currently enrolled in Medicare managed care plans.

Alternative solutions for acupuncture coverage lead to expensive differences in cost sharing – money that is paid for treatment. Studies found that private insurance plans with coverage for acupuncture required a $10 – $25 copayment per visit, with the insurance company paying the remainder of the bill. Several insurance plans excluded coverage for acupuncture.

3.1 Non-Medicare Insurance Coverage

A non-Medicare insurance coverage such as Medicaid or the State Children’s Health Insurance Programs (SCHIP) may pay for a service that Medicare labels as custodial care if the service has a therapeutic effect on an illness or injury. This is a complex issue and, in general, neither Medicare nor non-Medicare insurances are anxious to pay for long-term care or support services for the disabled. Although Medicaid is run by the states, it is a medical assistance program for low-income people and it must follow Medicare guidelines in paying for services. States have the option of providing home and community-based services for a limited number of people who are eligible for Medicaid. These programs provide services to help people who are eligible for Medicaid receive care at home rather than in an institution. If successful, this may shift the focus of coverage for long-term care services for the disabled from Medicare to Medicaid. A comprehensive understanding of modern Medicaid programs can be an important information base for disabled individuals currently covered by Medicare who are looking into future care options. Benefits vary by state and by group. Unfortunately, in the general milieu of tightening Medicare funding and restructuring programs, many states have cut Medicaid benefits for physical, occupational, and speech therapy. These therapy services are vital for many disabled people, particularly those with progressive diseases or recent injuries. Reductions in these therapy services are likely to increase demand for therapists working under gentle cure classifications. This demand might actually bring future success in obtaining therapy services for disabled individuals through non-Medicare insurances. [7][8][9][10][11]

3.2 Out-of-Pocket Expenses for Gentle Cures

Any family which acquires a large amount of medical expenses, but fails to qualify for the safety net at the end of the year can apply for a deferred rebate on the next tax return. This would be available as long as the patient can prove that he is entitled to safety net assistance in the coming year, but may experience difficulty in the event of medical unemployment or losing eligibility for the Medicare card.

In extreme cases of financial hardship, there are safety nets available for patients on a low income so they do not incur high levels of debt due to their medical expenses. This includes a low income health care card which entitles the holder to cheaper prescriptions and other concessions, and the aforementioned Medicare Safety Net. The safety net is in place to assist those holding Medicare cards who suffer large medical costs and is active from January 1 to December 31 each year. Once a patient or family reaches a certain threshold of out-of-pocket expenses, they will qualify to receive higher rebates, with additional assistance once a further threshold is reached.

As highlighted earlier, a new treatment can be anything up to 3 times the MBS fee and still only require the patient to pay the same amount and therefore costing not much more in relative terms. In the event of a treatment being much more expensive, the patient may decide to forgo medical treatment, instead receiving no gap treatment or going back to the standard practice on the belief that an extra cost will not equate to a better health outcome.

If the new treatment is not as effective as the old one, then the extra cost is still only 25% of the difference in cost between the two treatments. This is because Medicare will only fund treatment which has proved to be the most clinically effective available. If the new treatment is equally effective, then Medicare funding is still only 50% and again the patient must pay the additional cost out-of-pocket or by using his private insurance. Any Medicare funding on the treatment is available to the patient as a rebate, which can be claimed either as a direct transfer of the rebate amount into a nominated bank account, or deducted from the cost of the treatment at the practitioner’s discretion. Further information on this and eligibility for rebates can be found at the official Medicare website.

The out-of-pocket cost of a gentle cure to the patient is determined not only by the Medicare coverage, but also by the balance between the cost of a gentler alternative and its effectiveness compared to the conventional treatment it is being judged against. If the allowance for the treatment is the same as its conventional alternative, then Medicare will cover 75% of the fee for in-hospital treatment. Any extra cost must be paid by the patient, or through additional private insurance if the patient has such a policy. This could apply to a variety of treatments such as physiotherapy for a leg fracture using an ultrasound machine as opposed to regular therapy, or a change in drug prescription.

4. Conclusion

Through other publications, the policy clarifies a difference in benefits in the fee-for-service programs and Medicare Managed Care programs. People who are in a Medicare Managed Care or other Medicare health plan have the same benefits as other Medicare health insurance. Your plan must give you complete information about how your benefits will be affected if you enroll in the plan. At that time, you decide whether or not to enroll in the plan. This is a huge advantage and disadvantage over people with disabilities. In the same publication, the policy clearly states some more in-depth differentiation of eligibility. The benefits are there for people who are entitled to Part A and have a significant or continuing disability, which is another advantage over the elderly. These services are available for those people as well as some under age 65 with End-Stage Renal Disease (ESRD), amputations, or those who suffer from Sickle Cell Disease. This publication specifies the benefits available to these individuals contrasted with older adults, as well as those individuals who still get the same benefits if they are diagnosed with Alzheimer’s or from a recent stroke. The benefits for home health care are the same as those listed above. This can be helpful to someone with a disability who is in need of medical guidance at home. In another fact sheet addressing Medicaid and Home Health Services, Medicare is mentioned again in that a person eligible for both Medicare and Medicaid services can receive home health services under a home health coverage waiver.

Medicare coverage is available for home health services and supplies when the specific requirements of coverage are met. It is evident from the healthcare policy that coverage is available if the patient is homebound and needs skilled care. The policy fails to address the patient who is homebound and requires only unskilled care. Medicare will help cover the cost of a patient who is homebound and in need of skilled care. This is directly from the Medicare booklet; it mentions that “you have the right to get all of your healthcare information in a language you understand”.

References:

[1] E.K. Choo, C.J. Charlesworth, Y. Gu, C.J. Livingston, et al., “Increased use of complementary and alternative therapies for back pain following statewide Medicaid coverage changes in Oregon,” Journal of general internal medicine, vol. 2021. Springer, 2021. springer.com

[2] N. Ijaz and H. Carrie, “… pluralism: An environmental scan of the statutory regulation and government reimbursement of traditional and complementary medicine practitioners in the …,” PLOS Global Public Health, 2024. plos.org

[3] K.E. Anderson, D. Polsky, S. Dy, “Prescribing of low‐versus high‐cost Part B drugs in Medicare Advantage and traditional Medicare,” Health Services Research, vol. 2022. Wiley Online Library, 2022. nih.gov

[4] M. Candon, A. Nielsen, and J. A. Dusek, “Trends in insurance coverage for acupuncture, 2010-2019,” JAMA Network Open, 2022. jamanetwork.com

[5] B. J. Stussman, R. R. Nahin, P. M. Barnes, et al., “US physician recommendations to their patients about the use of complementary health approaches,” in Altern. Complement. Ther., vol. 26, no. 2, pp. 1-10, 2020. nih.gov

[6] A. L. Schwartz, K. Zlaoui, R. P. Foreman, et al., “Health care utilization and spending in Medicare Advantage vs traditional Medicare: a difference-in-differences analysis,” JAMA Health Forum, vol. 2, no. 7, 2021, pp. e211868-e211868. jamanetwork.com

[7] H. Borgstrom, G. Polich, H. Steere, I.S. Davis, et al., “Outpatient physical, occupational, and speech therapy synchronous telemedicine: a survey study of patient satisfaction with virtual visits during the COVID-19,” journal of physical medicine & rehabilitation, 2020, journals.lww.com. nih.gov

[8] L. Hodder, K. West, and V. Forkus, “Medicaid to Schools Technical Assistance Guide,” 2021. unh.edu

[9] R. C. Chu, C. Peters, N. De Lew, “State Medicaid telehealth policies before and during the COVID-19 public health emergency,” Department of Health and Human Services, 2021. hhs.gov

[10] J. Currie and A. Chorniy, “Medicaid and Child Health Insurance Program improve child health and reduce poverty but face threats,” Academic pediatrics, 2021. academicpedsjnl.net

[11] L. A. Bilaver, S. A. Sobotka, and D. S. Mandell, “Understanding racial and ethnic disparities in autism-related service use among Medicaid-enrolled children,” Journal of Autism and Developmental Disorders, vol. 51, no. 6, pp. 2271–2281, 2021. nih.gov